The Think Tank panel's comments and discussions are synthesized into summary statements and recommendations in two broad categories: Strategic Positioning (i.e., early success, partnerships, and platforms/consortiums) and Tactical Activities (i.e., key focus areas, methods and metrics, and training and capacity).
Few exemplary T4 research studies are available from high income countries (HICs) and even fewer from middle and low income countries (LMICs). Awareness of T4 research's importance is also very limited. Key strategies during the formative stages will be advancing the science of T4 research and gaining more broad appreciation for its role in creating new knowledge that can be used to refine health policies that lead to overall improved population health. It is desirable to have early T4 studies with high probability of measurable short term gains in capacity and observable health improvements. These early research efforts will facilitate more demand from all stakeholders.
Global health investments are common in HICs and some MICs. Global financial recessions are touching all countries, regardless of their wealth status and international investments will receive domestic scrutiny, and will often need to link back to assist domestic health challenges. Consider research investment models wherein HIC support their domestic research, some LMIC support their research with HIC supplements, and most/all LICs and some MICs receive HIC (or MIC) support.
Nurturing non-traditional partnerships for T4 research that include major academic health centers, philanthropic research organizations, and others in the public and private sectors will foster success. Developing key partnerships should utilize an opportunistic approach, seek where added value can be gained, and find win-win common goals. Stakeholders include local counterparts (e.g., researchers, communities, providers, and health care systems), national and local government (e.g., Ministries of Health, Local Health Bureaus), key global agencies (e.g., WHO, PAHO, World Bank, and regional development banks), US federal agencies (e.g., HHS Office of Global Affairs, USAID, HRSA, and CDC), and global health researchers within NHLBI and across NIH. Global health research platforms with NHLBI investments include the Global Health Initiative - Centers of Excellence, Global Alliance of Chronic Diseases, Global Alliance of Clean Cookstoves, and the Medical Education Program Initiative. In addition, NIH has investments in PEPFAR and the H3Africa. Full advantage should be taken of these important platforms to conduct T4 research.
"Best buy" interventions (e.g., counselling and multi-drug therapy for people with medium-high risk of developing heart attacks and strokes), promoted by WHO for LMIC, are considered affordable and feasible and are good targets for T4 research. Global health research strategies must invest where intervention can be effective in reducing health inequities across racial/ethnic groups, socioeconomic strata, and urban and rural settings. With LMIC heath care worker shortages common, alternative delivery models staffed by personnel similar to the community health worker (CHW) might be a viable strategy.
Groups at extreme high risk for poor outcomes for which proven effective interventions exist but their delivery lags, are key T4 research arenas. These may include sickle cell disease (SCD) in high burden regions, where provision of penicillin prophylaxis is lacking, and severe uncontrolled and untreated risk factors (e.g., blood pressure >180/120) for which basic pharmacotherapy could quickly and dramatically lower risk. Other opportunities include communicable diseases (e.g., HIV) that have become chronic in global populations and now are associated with chronic disease comorbidities. Testing implementation strategies for contextually and culturally adapted evidence-based clinical care guidelines with a focus on common diseases with large burdens such as hypertension/stroke, asthma, and COPD will be important.
The underlying drivers of shorter life expectancy and poorer health in the United States, relative to peer high-income countries, and the potential relationship to quality and access to care and variation in social determinants of health need further exploration. Comparative national studies of implementation challenges and examining natural experiments from policy variation across and within countries should be considered, as they can inform T4 translation and implementation strategies in the United States.
The use of mixed methods research designs should inform earlier stages of research. Employing big data analyses and predictive modeling may help intervention development. Complex, multilevel, and multifaceted interventions require input from key personnel knowledgeable of the challenges within each level. Methods with innovative study designs, creative uses of existing data, and novel analytical approaches and metrics that can better elucidate complex causal pathways, are needed. Cluster randomized community designs lend themselves better than other designs to larger scale complex interventions, provided adequate statistical power can be achieved. Employing big data analyses and predictive modeling will help intervention development. Business and entrepreneurial strategies may prove useful in many LMIC settings as will the use of inexpensive technologies (e.g., cell phones and point of care technologies).
Sound metrics are needed not only to assess qualitative outcomes (e.g., acceptability, fidelity, cost, and sustainability) of T4 research, but also intermediate outcome measures (e.g. blood pressure reduction), and population level impact measures (e.g., morbidity, mortality). Measuring the overall impact of new knowledge from T4 research is challenging because publication bibliometric of high impact scholarly journals may not fully capture it.
A new cadre of investigators (including mentors) with knowledge and skills to conduct T4 research using integrated approaches that address health inequities both domestically and globally, are needed. The NIH/NHLBI portfolio of K, F, and T awards needs to be leveraged to accommodate junior and young investigators interested in T4 research skills development. Embedding training and capacity building with funded T4 research will provide needed new knowledge for implementation and a sound learning environment. The National Center for Advancing Translational Sciences (NCATS) should play a key role in capacity development and training.
Ivor J. Benjamin, M.D., F.A.H.A., F.A.C.C., Medical College of Wisconsin
Barbara Bowman, Ph.D., Centers for Disease Control and Prevention
Neal Brandes, M.P.H., U.S. Agency for International Development
William Checkley, M.D., Ph.D., Johns Hopkins University
Pamela S. Douglas, M.D., M.A.C.C., F.A.S.E, F.A.H.A., Duke University School of Medicine
Sameh El-Saharty, M.D., MSc., M.P.H., The World Bank
Majid Ezzati, MEng., Ph.D., Imperial College London
Anselm Hennis, M.D., MSc., Ph.D., F.R.C.P, F.A.C.P., Pan American Health Organization
Judith S. Hochman, M.D., M.A., New York University School of Medicine
Lixin Jiang, M.D., Ph.D., F.A.H.A., F.A.C.C., Fuwai Hospital, CAMS.
Harlan Krumholz, M.D., Yale University School of Medicine
Gerard LaForgia, Sc.D., M.S., The World Bank
Gabrielle Lamourelle, M.P.H., U.S. Department of Health and Human Services
Julie Makani, M.D., Ph.D, F.R.C.P, Muhimbili University of Health and Allied Sciences
Shanthi Mendis, M.B.B.S, M.D., F.R.C.P., F.A.C.C., World Health Organization
K.M. Venkat Narayan, M.D., MSc., M.B.A., Emory University
Kwaku Ohene-Frempong, M.D., The Children's Hospital of Philadelphia
Paul M. Ridker, M.D., M.P.H., F.A.H.A., F.A.C.C., Brigham and Women's Hospital
Uchechukwu K. A. Sampson, MB.BS, MSc., M.B.A., M.P.H., F.A.C.C., Vanderbilt University School of Medicine
Sharon E. Straus, M.D., H.B.Sc., MSc., F.R.C.P.C., University of Toronto
David Stuckler, M.P.H., Ph.D., Hon. M.F.P.H., F.R.S.A, Oxford University
NIH Institutes and Centers
John M. Balbus, M.D., M.P.H, National Institute of Environmental Health Sciences
David A. Chambers, D.Phil., National Institute of Mental Health
Eleanor K. Hoff, Ph.D., National Institute of Diabetes & Digestive & Kidney Diseases
Georgeanne E. Patmios, Division of Behavioral and Social Research
Walter J. Koroshetz, M.D., National Institute of Neurological Disorders and Stroke
Mia R. Lowden, Ph.D. , National Institute of Allergy and Infectious Diseases
Amy Patterson, M.D., Office of Science Policy, National Institutes of Health
Emmanuel Peprah, Ph.D. , National Institutes of Child Health and
Maria A. Said, M.D., M.H.S., Fogarty International Center
Edward (Ted) L. Trimble, M.D., M.P.H., National Cancer Institute
Gary H. Gibbons, M.D., Director
Nakela L. Cook, M.D., M.P.H., F.A.C.C., Chief of Staff
George A. Mensah, M.D., F.A.C.C., Center for Translation Research and Implementation Science
Michael M. Engelgau, M.D., F.A.C.P., (Think Tank Lead), Center for Translation Research and Implementation Science
Peter G. Kaufmann, Ph.D., Center for Translation Research and Implementation Science
Helena O. Mishoe, Ph.D., M.P.H. , Center for Translation Research and Implementation Science
Chitra Krishnamurti, Ph.D. (Think Tank Co-Lead), Center for Translation Research and Implementation Science
Robert S. Balaban, Ph.D., Division of Intramural Research
Leslie R. Bassett, Center for Translation Research and Implementation Science
Deshirée Belis, M.P.H. , Center for Translation Research and Implementation Science
Glen C. Bennett, M.P.H. , Center for Translation Research and Implementation Science
Jodi B. Black, Ph.D., Division of Extramural Research Activities
Allison T. Borst, Center for Translation Research and Implementation Science
Josephine E. Boyington, Ph.D., M.P.H., Division of Cardiovascular Sciences
Janita M. Chicquelo-Coen, Center for Translation Research and Implementation Science
Tony L. Creazzo, Ph.D., Division of Extramural Research Activities
Mishyelle I. Croom, M.A. , Center for Translation Research and Implementation Science
Janet M. de Jesus, M.S., R.D. , Center for Translation Research and Implementation Science
Cynthia E. Dunbar, M.D., Division of Intramural Research
Nara Gavini, Ph.D. , Center for Translation Research and Implementation Science
Dinari A. Harris, Ph.D., Center for Translation Research and Implementation Science
Lenora E. Johnson, DrPH, M.P.H, Office of Health, Education, Communication and Science Policy
W. Keith Hoots, M.D., Division of Blood Diseases and Resources
Michael S. Lauer, M.D., Division of Cardiovascular Sciences
Stephen C. Mockrin, Ph.D., Division of Extramural Research Activities
Mark E. Parker, Center for Translation Research and Implementation Science
Emmanuel Peprah, Ph.D., Center for Translation Research and Implementation Science
Antonello Punturieri, M.D., Ph.D., Division of Lung Diseases
Monica R. Shah, M.D., M.H.S., M.S.J., Division of Cardiovascular Sciences
Susan T. Shero, M.S., B.S.N. , Center for Translation Research and Implementation Science
Jovonni R. Spinner, M.P.H., C.H.E.S. , Center for Translation Research and Implementation Science
Gail G. Weinmann, M.D., Division of Lung Diseases
Quanita L. Winters-Tyler, Center for Translation Research and Implementation Science
Neal S. Young, M.D., M.A.C.P., Division of Intramural Research
Shimian N. Zou, Ph.D., Division of Blood Diseases and Resources